A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

Inform the client that the nurse will get reprimanded for not administering the medication

Document the client’s refusal on the medication administration record

Ask the client the reason for refusing the medication

Inform the client that refusal is not permitted and it is required that the client take the medication

Answer and Explanation

The Correct Answer is C

Choice A reason: Informing the client about potential nurse reprimands is coercive and inappropriate, as it prioritizes the nurse’s interests over patient autonomy. This approach fails to explore the client’s reasons for refusal, which may involve side effects or mistrust, and does not support therapeutic communication or ethical care.

Choice B reason: Documenting refusal is necessary but not the first action. Exploring the reason for refusal allows the nurse to address concerns, potentially resolving issues like misunderstanding or side effects. Documentation follows after attempts to understand and educate, ensuring a therapeutic approach before recording the refusal.

Choice C reason: Asking the reason for refusal respects autonomy and initiates therapeutic communication. It identifies barriers like side effect fears or lack of understanding, enabling education or alternative solutions. This approach aligns with patient-centered care, addressing underlying issues to promote adherence while respecting the client’s rights.

Choice D reason: Stating that refusal is not permitted is coercive and violates autonomy. Clients have the right to refuse medication unless under involuntary treatment orders. This approach damages trust, escalates resistance, and contradicts ethical principles, making it an inappropriate initial response to medication refusal.

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Correct Answer is C

Explanation

Choice A reason: Schizophrenia alone does not typically warrant court-mandated outpatient treatment unless associated with criminal behavior. Living with family suggests stability, reducing the likelihood of court intervention. Mandates are linked to legal infractions, not diagnosis alone, making this client less likely for mandated treatment.

Choice B reason: Petty theft may lead to legal consequences, but courts typically mandate treatment for offenses directly tied to mental health or substance use, like DUI. A single theft may not justify mandated outpatient mental health treatment unless it explicitly stems from a diagnosable condition requiring intervention.

Choice C reason: Two DUI offenses indicate repeated substance use (alcohol) posing public safety risks. Courts often mandate outpatient treatment for substance abuse in DUI cases to address addiction and prevent recidivism, making this client the most likely to receive a court-ordered treatment mandate for outpatient care.

Choice D reason: Job loss due to depression does not typically result in court-mandated treatment, as it lacks a criminal component. Treatment may be recommended, but courts intervene when behavior poses legal or safety risks, like DUI, making this client less likely for mandated outpatient treatment.

A. Advance the catheter 2 to 4 cm further into the peritoneal cavity B. Infuse 50 mL of additional dialysate C. Aspirate from the catheter using a 60-mL syringe D. Reposition the client to facilitate drainage

Correct Answer is D

Explanation

Choice A reason: Advancing the catheter further risks perforation or malposition, potentially damaging peritoneal tissues or organs. Slow drainage is often due to positional obstruction or constipation, not catheter depth. This invasive action requires medical orders and imaging confirmation, making it inappropriate as a first step in addressing slow drainage.

Choice B reason: Infusing additional dialysate worsens abdominal distension and does not address slow drainage. It may increase intra-abdominal pressure, causing discomfort or complications like hernia. The issue is outflow obstruction, not insufficient dialysate, so adding more fluid is counterproductive and could exacerbate the client’s condition.

Choice C reason: Aspirating with a syringe is not standard practice and risks introducing infection or damaging the catheter. It does not address underlying causes like positional obstruction or fibrin clots. Medical evaluation or specialized interventions like heparin instillation are needed for persistent drainage issues, making this action inappropriate.

Choice D reason: Repositioning the client facilitates drainage by relieving positional obstructions, such as catheter kinking or omental wrapping, common in peritoneal dialysis. Changing positions (e.g., side-lying or sitting) promotes gravity-assisted flow, reducing abdominal girth and improving exchange efficiency. This non-invasive action is the safest and most effective initial step.

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A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of clients in the mental health outpatient clinic. Which client is most likely to be mandated by a criminal court for outpatient treatment?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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